Can occupational therapy and physical therapy co-treat in acute care?

Today, we’re going to be answering a question I get in my DM’s all the time: can occupational therapy and physical therapy co-treat in acute care? 

The short answer is yes! OT and PT can co-treat in acute care. However… whether or not both disciplines can bill for their services during a co-treat is a different story. 

In this article, we’ll cover:

• What is co-treating in acute care
• Who can co-treat in acute care
• How to bill for co-treatment under Medicare Part A and Medicare Part B
• How to document co-treatments
• Different examples of co-treating
• Co-treating outside of the hospital 

Some disclaimers before we get started. I’m going to be explaining how co-treating works in acute care (AKA the hospital) under Medicare Part A and Medicare Part B. If your patient is on Medicare Advantage, which is run by private health insurance companies, or on some other type of insurance, what I’m saying may not apply to them. 

Throughout this article I will also be talking about skilled services. I recommend checking out this article and podcast to get a grasp on all things skilled services, as it has a direct impact to what is billable during co-treating. 

Ep. 26: Can OT and PT Co-Treat in Acute Care

What is co-treating in acute care? 

Simply put, co-treating is when two disciplines each provide skilled, reasonable, and necessary services to the same patient at the same time. Co-treating isn’t the same thing as concurrent or group therapy where one therapist is treating multiple patients. While this may seem simple, there are always gray areas and nuances to co-treating, and information can be hard to find.

One reason for this is that CMS doesn’t even call it co-treating! All of the official CMS documents refer to it as team-treating (I don’t even want to tell you how many hours that took me to figure out).

Co-treating comes up a lot in acute care, as patients are more medically fragile and more often warrant a co-treat where two skilled disciplines need to work together to provide an effective intervention. In facilities where patients may be less acute, co-treating is not as common of an occurrence. 

AOTA has published joint guidelines with ASHA and APTA on this topic. Co-treating can only be done if both therapies working together will benefit the patient. For example, a physical therapist can focus on weight shift and core stability while an occupational therapist facilitates upper body dressing. 

Co-treating is NOT:

• Following behind the patient with a wheelchair
• Gathering supplies 
• Waiting in the room for the other therapist to finish
• Providing standby assist during a transfer
• Seeing a patient at the same time out of convenience or for scheduling purposes

These are examples of activities that are not considered billable time for co-treating under occupational therapy because they are not skilled services. While you may be helping a team-member out you can’t bill the patient for that service if it doesn’t meet coverage criteria. 

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Who can co-treat in acute care?

It is recommended that only two disciplines can co-treat at the same time. While I haven’t found any guidance that technically prohibits all three therapies treating one patient at the same time, justifying that all three are providing a skilled intervention at the same time to the same patient would be… a stretch.. 

In this hospital, co-treating most commonly occurred between occupational therapy and physical therapy. Occasionally, you will see co-treats between OT and speech or speech and PT, but it’s just not as common as the OT/PT scenario. 

Can OT and OTA co-treat? 

If an OT and an OTA are treating a patient at the same time, only one of you can bill for that time. Now, if you’re passing the patient off, like the OTA takes the patient for 15 minutes and then the OT sees the patient for 15 minutes, then the OTA and OT could each bill one unit of time (you might have it on the same note though). 

However, if the OTA or OT is assisting the other one with a transfer or facilitating an intervention, one of you is essentially serving as a tech. You cannot each bill for an OT visit at the same time even if both of you are providing skilled services. So, this situation isn’t considered co-treating. 

How to bill for co-treating in acute care

As always, healthcare is a business, and your facility wants to make sure that you are billing for your services correctly. You also want to make sure you’re billing for your services correctly to avoid committing fraud or filing a false claim. 

How to bill for a co-treat depends on what plan you are billing. For Medicare beneficiaries in acute care this could be Medicare Part A or Medicare Part B. Billing for a co-treat incorrectly could lead to you over or under billing for your time. 

The first step of billing for co-treating in acute care is to determine if the patient is admitted under an inpatient status or observation/outpatient status. 

Co-treating for Medicare Part A

If a patient is admitted to the hospital as an inpatient status, their stay is billed under Medicare Part A, and paid through Diagnostic Related Groups. DRGs are a lump-sum bundled payment which essentially means your services are not separately reimbursed. They are just included in the one payment for the episode of care. 

Under this payment model, your hospital may put an emphasis on providing the best outcomes with the least amount and shortest visits possible, including therapy services. Because, although therapy can and does positively influence reimbursement under DRGs, it is also seen as a line item deduction from the overall revenue because it isn’t separately covered. 

However… just because we don’t get paid separately for our services under DRGs, this doesn’t mean that you can just “bill” for your entire intervention item automatically during a co-treat. You can only bill for the minutes where you are providing a skilled, reasonable, and necessary intervention. Meaning, you AND the PT/PTA must both be providing a skilled, reasonable, and necessary intervention at the SAME time, then you can both bill for that time. If you can’t check all those boxes, then you can’t both bill for the full session time. 

Co-treating for Medicare Part B

If a patient is at the hospital is not admitted then they are under observation/outpatient status. Observation and outpatient stays are billed under Medicare Part B through CPT® codes in a fee-for-service model. Most of these codes are timed-codes that are billed in units. During co-treatments under Medicare Part B, only one therapy practitioner can bill for that time even if both disciplines are providing a skilled intervention. (This is why companies don’t like practitioners to co-treat will Part B patients). 

So how does this work in practice? Generally clinicians might split the minutes based on units. However, if the total treatment time was only one unit then only one clinician can bill for that time. 

For example, if the session lasts 20 minutes. That is only one unit of time under the 8-minute rule, so either OT or PT could bill one unit and the other wouldn’t bill anything for their visit. You cannot each bill 10 minutes and each bill one unit. 

However, if the visit was 25 minutes, this would be two units. So each discipline could bill one unit apiece.

However you divvy up the minutes, just make sure it aligns with what is documented in your note and is appropriate. While many clinicians may split the minutes 50/50 this is not always recommended as it is rarely that straight forward. Obviously, it isn’t practical to use some sort of stopwatch, but do your best to make an educated estimate as to how much time was spent on each code billed. 

(P.S. if the idea of patients being different status in the hospital is something new, you might want to check out the Amplify OT Membership, which includes my Mastering OT Policy and Medicare Course for free. This is a great way to learn how our healthcare system works within a supportive community.)

Documenting a co-treat

Documentation should clearly indicate the rationale for co-treatment. You also want to make sure that evidence of your skilled intervention is documented to support what you are billing for especially if you both are billing for the time. Each practitioner would submit their own note for the visit. 

And with any other visit, each therapy practitioner should document what goals were addressed, progress, patient response, etc., that supports codes selected and the reason for therapy services. 

Co-treating in Acute Care Examples

Okay, let’s put all of this in context! 

Co-treating an Evaluation in the ICU

The occupational therapist and the physical therapist are completing an evaluation for a patient in the ICU. The patient is medically fragile and there are many lines and leads that need to be managed. They’re both in the room for 30 minutes. Both OT and PT are working together to formulate the patient profile, formulate the patient goals, and complete a functional evaluation. 

Due to the medical complexity, the skill of both practitioners is needed to monitor vitals, patient status, and adjust the intervention to fit the patient’s needs. This is a scenario where having assistance from the tech may create a safety issue for the patient. 

Both the OT and PT could potentially charge an eval, as well as their appropriate treatment codes, for a total of 30 minutes of intervention time. 

When the patient ends up not needing a co-treat

A patient was admitted to the hospital a few days ago as an inpatient status. An OT and a PTA go in to see them at the same time for a 30 minute treatment session. The patient was appropriate for a co-treat yesterday and has a busy schedule later today. So, the OT and PTA decided to go together for today’s session to make sure they get their visit in. 

Today, the patient is having a good day. The clinicians have two options: one of them could leave and come back later, or they both stay and take turns being the ‘lead’ and being the ‘tech’. 

In this session, the PTA provides additional hands-on assistance at the start of the session while the OT facilitates the patient getting dressed and performing self care at the edge of the bed.  Then the OT provides a wheelchair follow while the PTA provides an intervention around gait in the hallway. When they get back to the room, the PTA goes to get more equipment while the OT has the patient stand at the sink for grooming.

In this scenario, even though both clinicians were in the room, only one of them is providing a skilled service at a time. Even though the PTA or OT are providing assistance from time to time, their assistance doesn’t not require their unique training (i.e. the intervention isn’t skilled) so they cannot bill for that service. 

So, in this case, you need to figure out when you were providing a skilled service and only bill for that time. Since this visit is under a DRG, there may not be units of CPT® Codes involved. However, if you are using units, you should only each report one unit since the total intervention time was only 30 minutes and only qualifies for two units to be billed. 

Exception: 

If this was a different patient and both were providing a skilled service during portions of the session, then both practitioners may be able to bill for portions of the same time. 

Co-Treating a Patient on Observation Status

A patient is admitted to the hospital under an outpatient/observation status. An OTA and PT go in to see the patient for a 30 minute intervention session. The OTA and PT provide skilled intervention together for 30 minutes.

This is where billing under Medicare Part B looks a little different. Even if two therapy practitioners are both in the room for 30 minutes providing a skilled service at the same time for the entire time, only one of you can bill for those minutes. In this case, the OTA billed for 18 minutes and the PT billed for 12 minutes – each billing one unit.

What about co-treating in skilled nursing facilities or other settings? 

When it comes to other settings, it again comes down to billing. If a service is covered under Medicare Part A, you generally aren’t billing 1:1 for your time like you are under Medicare Part B so you can both ‘bill’ for that session. Meaning, you can both disciplines can codes for the entire treatment time. However, if you are billing Part B, regardless of the setting, you must follow the Part B guidance of splitting your time.  Details on co-treat in SNF is more thoroughly spelled out in the CMS MDS manual.

Many of these other settings discourage co-treats but it doesn’t mean you can’t technically do it. However, as with anything, make sure you back up your reasoning as to why it is the best option for the patient and why the intervention requires two skilled practitioners. 

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The Financial Argument For or Against Co-Treating

Especially in Medicare Part B scenarios, facilities often strongly discourage co-treating because it does not make fiscal sense. I get into detail on this in the podcast, but the general summary is that the employer is essentially paying two practitioners their full wages to get reimbursed half as much. 

On average, a 60 minute Part B visit may reimburse around $100. So, if the OT and PT each get paid $40/hour, then the employer only has a $20 profit margin on this visit. Vs if they provided the visit separately, there would be a $120 profit (this is of course an oversimplification that doesn’t include cost of benefits, rent, supplies, etc.).

So, you can see why from a financial standpoint, co-treating Part B patients does not make a lot of sense. You’d have to make a strong case for why a co-treat is necessary and why a tech or second person would not be at all appropriate. 

For Part A, there is still a financial element in where the facility sees it as paying two practitioners to do one visit when they could pay one practitioner to do the same visit. So again, there needs to be a good argument as to why to co-treat is appropriate and will help the patient progress more quickly than two separate therapy visits. 

Co-treating needs to ultimately be about the patient. When we co-treat this often means the patient is receiving only one therapy visit that day instead of two. So we must also think about are we really doing this because it is the best way to progress the patient, or are we doing this because we want a buddy or our tech isn’t sufficiently trained. 

I love co-treating… but is it always the right choice? 

Overall, we need to think about the real reason for why we are co-treating. I, just like anyone else, love to co-treat with my coworkers. It’s nice to know I have someone I can trust in the room especially if I’m nervous to see a new patient or am on a new floor. 

I co-treated a lot when I first started seeing patients on the ICU. However, my lack of skill shouldn’t be a justification for billing for a service. We must put ourselves in the shoes of the employer, the payer, and the patient to ensure we are making the right decision. 

If you’re having issues at work or with co-workers around co-treating, try engaging in an open conversation and develop an evidence-based approach to this type of session which can have a lot of benefits, but also has a lot of other considerations. 

Want to learn more about this and how to navigate our healthcare system?

If you want to feel confident finding answers to questions like this or understanding the policies that influence everything about your job, then I really encourage you to check out the Amplify OT Membership. 

This is a great community of practitioners all asking questions and finding answers about the healthcare policies in their setting. In addition, you get access to all Amplify OT courses for FREE (hello, CEU’s!) and exclusive content not available on the general site. Just like this article and podcast, all of my courses are founded in policy and practice so you can get an idea of what the heck a document is saying before trying to read it for yourself. Think of it like good ol’ Spark Notes for Medicare 😉 Hope to see you there!

Resources 

• Amplify OT – What is skilled occupational therapy?
• Amplify OT – Reimbursement models in OT
• Amplify OT – How to bill OT under Part B
• Amplify OT – How to bill using the 8 minute rule
• Amplify OT – How insurance influences plan of care
• AOTA – Joint guidelines for co-treating
• CMS – Acute PPS
• CMS – Part B billing scenarios for OT and PT

Special thanks to Lindsay Bright, OTD/S for her contributions on this article.